Monday, April 21, 2014

Empathy plays an important role in all of healthcare communication, but it's especially heightened when clinicians are working with patients with serious illness and their families.

Journal of Palliative Medicine published an article by Vital Talk's Tony Back and Bob Arnold recently about the role empathy can play in the delineation of goals of care for seriously ill patients. Empathy without any specific action is valuable to the suffering person. Merely being understood often times has some ameliorative impact on the suffering person and fosters a therapeutic relationship, even when some problems cannot be solved.

However, in the face of insoluble problems (e.g. cancer not responding to chemotherapy), patients understandably want helpful action, and clinicians still want to act. Do something that will help me! What can I do to help myself? The question is, how do we figure out how to direct both our energy and the patient's?

Back, Arnold, and others have written extensively on this topic, and the current article adds even more nuance to goals of care exploration. They write about how patient emotion can be translated into meaningful action that moves patients towards achievable goals of care. They recommend the following steps:

See affect as a "spotlight"- be curious about the reasons for the emotion. Don't assume sadness is exclusively about dying. The first step is merely recognizing the spotlight, even if it's not patently obvious where it's shining.

Use the affect to connect with the patient- bring it out in the open to demonstrate for the patient that you are noticing it. They recommend doing this before moving on to figuring out what is being spotlighted.

Read between the lines to infer what is important- listen for cues that suggest a deeper concern or narrative that isn't being openly talked about. The evidence here will be incomplete, and the clinician needs to hypothesize and test the hypotheses with the patient.

Develop action plan jointly with patient to address the need. The patient needs to be committed to the plan, and when a patient is committed to action that helps them address the goal, the process is defined as a success.

Image: FracFX "In the Spotlight"

The "goals of care" concept is already patient-centered and the described process adds to the patient centered-ness of it. You don't automatically know what the patient's affect is about. There's some guesswork. But you're not going to move to an action plan until the patient confirms you've got it right AND that they are committed to the plan. Step 4 suggests a role for patient behavior change in the goals of care process: What can patients do to help themselves achieve important goals? In the face of serious illness, patients frequently feel like they lose control over activities in their life. Exploring emotions that might arise from this loss can help us figure out how to help patients restore some semblance of control.

This newly described process shares elements similar to other communication skills and processes taught by Vital Talk. It's not meant to be a dogmatic process, but rather a distillation of small ingredients essential to meaningful conversations about serious illness.

Vital Talk has some upcoming training opportunities for both clinicians wishing to improve their own communication skills and also for educators wishing to improve their teaching of communication skills. Having been through both types of training before, I would use the following descriptors: high yield, dynamic, supportive, fun, and life-long. In addition to coming home with improved communication and teaching skills, you also come home with a process for how to continue your improvement.

See here for more on my experience with a Vital Talk faculty development program for teaching communication.

Back AL, & Arnold RM (2014). "Yes it's sad, but what should I do?" Moving from empathy to action in discussing goals of care. Journal of Palliative Medicine, 17 (2), 141-4 PMID: 24359216

Pallimed: A Hospice & Palliative Medicine Blog Founded June 8, 2005.
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